Corrective Action Plans

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Finding 2024-002 Description of Finding Significant Deficiency in Internal Control over Compliance, and Other Matter Statement of Concurrence or Nonconcurrence The Town concurs. Corrective Action The Town agrees with this finding and will ensure the Board of Education department heads and Director...
Finding 2024-002 Description of Finding Significant Deficiency in Internal Control over Compliance, and Other Matter Statement of Concurrence or Nonconcurrence The Town concurs. Corrective Action The Town agrees with this finding and will ensure the Board of Education department heads and Director of Operations sign all invoices. Name of Contact Person Robert Buden, Director of Finance Completion Date May 20, 2025
Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Plan: The Director of Finance, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the nu...
Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Plan: The Director of Finance, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Kayla Gipson, Director of Finance Management Response: Agree with the finding. In FY24, we implemented a new accounting software. The Director of Finance will ensure additional appropriate action is taken to reduce the number of entries proposed by the auditors and ensure fully adjusted financial statements are prepared prior to fieldwork.
Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct payroll liabilities that were improperly recorded in prior years. Plan: The Council and Director of Finance will implement internal controls to properly record payroll liabilities on a timely...
Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct payroll liabilities that were improperly recorded in prior years. Plan: The Council and Director of Finance will implement internal controls to properly record payroll liabilities on a timely basis prior to audit fieldwork. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Kayla Gipson, Director of Finance Management Response: Agree with the finding. In FY24, we implemented a new accounting software. The Director of Finance will implement additional internal controls to ensure payroll liabilities are recorded properly.
Audit Finding Reference: 2024 - 001 Planned Corrective Action: BRHP continues weekly reporting of Request for Tenancy Approval processing and HAP Contract executions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Hiring and retention of staff wh...
Audit Finding Reference: 2024 - 001 Planned Corrective Action: BRHP continues weekly reporting of Request for Tenancy Approval processing and HAP Contract executions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Hiring and retention of staff while also managing through transitions remains a focus to preserve continuity for Housing Choice Voucher functions. Name of Contact Person: FaShaunDa Walton, Housing Mobility Director, fwalton@brhp.org Anticipated completion date: December 31, 2025
Finding 561271 (2024-001)
Significant Deficiency 2024
Corrective Action Plan Emory University Office of Financial Aid Prepared by John Leach, Assoc Ve Prov/Dir, Univ Fin Aid, Office of Financial Aid Federal Program: Federal Direct Student Loans (ALN 84.268} CFR 200.303/685.300(b)(S0) Federal Award Year: September 1, 2023 to August 31, 2024 Federal Agen...
Corrective Action Plan Emory University Office of Financial Aid Prepared by John Leach, Assoc Ve Prov/Dir, Univ Fin Aid, Office of Financial Aid Federal Program: Federal Direct Student Loans (ALN 84.268} CFR 200.303/685.300(b)(S0) Federal Award Year: September 1, 2023 to August 31, 2024 Federal Agency: U.S. Department of Education Finding 2024-001: Cash Management The reconciliation between ED's records (School Account Statements) and the school's financial and business records were prepared timely throughout the year; however, the differences identified in the reconciliation were not accounted for and no review or segregation of duties was documented as part of that process. Management Response and Corrective Action Plan: The finding was primarily caused by an unforeseen staff shortage. This led to one person being the preparer and reviewer with no segregation of duties. Although the differences were identified, they were not documented on the reconciliation form. To resolve this finding, the Office of Financial Aid {OFA) has hired new employees and implemented a new process. The Financial Operations Team is now fully staffed with two senior accountants and one senior director. As part of our ongoing efforts to strengthen internal controls and ensure the integrity of our processes, we have implemented a segregation of duties framework. This approach will help us clearly define roles and responsibilities, ensuring that critical tasks are divided among different individuals. By doing so, we will meet compliance requirements, reduce errors, and promote accountability within our office. One senior accountant will prepare the monthly reconciliation by the 10th of the following month. The senior director will review the monthly reconciliation by the 15th of the following month. In the absence of the initial preparer/reviewer, the executive director of OFA will take on the reviewer role. We understand that proper documentation is crucial for clarity, tracking, and future troubleshooting. The differences/discrepancies that are identified in the reconciliation process will be accounted for through proper documentation on the reconciliation form, which will be reviewed/investigated by a second reviewer. The Financial Operations Team within the OFA will continue to create timely and accurate monthly Federal Direct Student Loan reconciliations that compare OPUS (Emory), General Ledger (Emory), Student Account Statement-SAS (U.S. Department of Education), and GS (U.S. Department of Education). Anticipated Completion Date The corrective action plan was implemented for FY 24-25 (September 1, 2024). Responsible Department: Office of Financial Aid John B. Leach, Associate Vice Provost for Enrollment and University Financial Aid Suite 300 Boisfeuillet Jones Center 200 Dowman Drive Atlanta, Georgia 30322
The Authority obtained answers from USDA to questions specific to the Authority's operations after the due date of the semiannual report. The Authority will be proactivt to follow up with USDA when questions and information are submitted for preliminary review. Reports will be prepared and submitted...
The Authority obtained answers from USDA to questions specific to the Authority's operations after the due date of the semiannual report. The Authority will be proactivt to follow up with USDA when questions and information are submitted for preliminary review. Reports will be prepared and submitted in a timely manner.
The Housing Authority will implement a standardized process for documenting rent reasonableness across all tenant files, including those from the Emery County merger, and will explore automated tools to streamline the determination and documentation process. Staff will also receive training to ensur...
The Housing Authority will implement a standardized process for documenting rent reasonableness across all tenant files, including those from the Emery County merger, and will explore automated tools to streamline the determination and documentation process. Staff will also receive training to ensure compliance with the requirements moving forward.
Department of Health and Human Services 2024-001 Procurement Recommendation: We recommend that the Organization develop a written procurement policy that meets the requirements noted in Section 200.318 of the Code of Federal Regulations. Explanation of disagreement with audit finding: There is no...
Department of Health and Human Services 2024-001 Procurement Recommendation: We recommend that the Organization develop a written procurement policy that meets the requirements noted in Section 200.318 of the Code of Federal Regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: While the Organization had a procurement policy in place for the entire year, until October 1, 2024 it was noncompliant with the requirements of Title 2, Subtitle A, Chapter 2 Part 200, Subpart D, section 200.318 of the Code of Federal Regulations. The new policy was implemented on October 1, 2024 and there were no instances of noncompliance after this date. It is the opinion of the organization that this finding has therefore already been resolved. Name(s) of the contact person(s) responsible for corrective action: Erica Vogt, CFO Planned completion date for corrective action plan: Already resolved
Finding No, 2024-002 DATA COLLECTION FORM DUE DATES We acknowledge the audit finding regarding the untimely submission of the Data Collection Form (DCF). We recognize the importance of timely filing in compliance with federal requirements and are committed to addressing this issue. To ensure the DCF...
Finding No, 2024-002 DATA COLLECTION FORM DUE DATES We acknowledge the audit finding regarding the untimely submission of the Data Collection Form (DCF). We recognize the importance of timely filing in compliance with federal requirements and are committed to addressing this issue. To ensure the DCF is filed on time in the future, we will implement improved communication and coordination between our finance team, external auditors, and relevant stakeholders. Specifically, we will: • Establish an internal timeline aligned with federal deadlines, • Schedule earlier engagement and planning meetings with the audit team, • Assign clear roles and responsibilities to team members, and • Monitor progress regularly to ensure timely completion of audit-related tasks.
Finding No. 2024-001 NONCOMPLIANCE WITH US GAAP – VARIABLE INTEREST ENTITIES (VIE) We acknowledge the audit finding and appreciate the auditor’s diligence in identifying the issue. After evaluating the matter, we agree that the effect on the consolidated financial statements is immaterial and does n...
Finding No. 2024-001 NONCOMPLIANCE WITH US GAAP – VARIABLE INTEREST ENTITIES (VIE) We acknowledge the audit finding and appreciate the auditor’s diligence in identifying the issue. After evaluating the matter, we agree that the effect on the consolidated financial statements is immaterial and does not impact the fair presentation of our financial position, results of operations, or cash flows. Additionally, after assessing the costs and benefits of remediation, we have determined that the corrective action required to fully address this issue is not cost-effective at this time. The resources required would outweigh the potential benefits, particularly given the immaterial nature of the issue and the lack of impact on users of the financial statements. We, will continue to monitor this area as part of our internal controls framework and will reassess if conditions change or if the issue becomes material in future periods.
Although there was a procedure in place for timely reporting of withdrawals, an employee retirement caused the lapse in reporting. As a safeguard in the future, we have updated the documents procedures to indicate that all documents will be sent digitally to the registrar’s office, rather than a com...
Although there was a procedure in place for timely reporting of withdrawals, an employee retirement caused the lapse in reporting. As a safeguard in the future, we have updated the documents procedures to indicate that all documents will be sent digitally to the registrar’s office, rather than a combination of paper delivery and/or email. By only email delivery, a trail can be followed to ensure both offices have received notification that the withdrawal process and its completion. As an additional safeguard, a regular review between all offices that manage student withdrawals will be conducted to ensure student cases have been completed timely. The email communication plan was put into place on February 13th, the monthly review will begin with the Month of March 2025.
Finding 561177 (2024-003)
Significant Deficiency 2024
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a peri...
Finding no.: 2024-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a period of transition of management in the property management department. The funding processes have been reestablished and procedures are in place to ensure there are no unplanned lapses in funding the reserve going forward. Anticipated completion date: February 2025
Finding 561176 (2024-002)
Significant Deficiency 2024
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing ...
Finding no.: 2024-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2024-001 will serve to accelerate closing procedures and help the audit to be completed on schedule allowing for the required calculation and deposit of the residual receipt reserve funds within the required time frame. Anticipated completion date: October 2025
Finding 561175 (2024-001)
Significant Deficiency 2024
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls r...
Finding no.: 2024-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Radha Mehrotra, Controller for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2025
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, a...
The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Agency has determined that the cost of eliminating this material weakness in internal control would exceed its benefit.
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, howe...
The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job...
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job duties of the Finance Director and appropriate staff will be trained as back-up. We have a third party outside accountant that prepares quarterly and annual reporting. All reports are reviewed by the Executive Director, the Finance Director and the third-party accountant to ensure that the reports are accurate. After the initial review, the third-party accountant is present at the finance committee when the reports are presented. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: June 30, 2025
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent ...
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent policies for grant management, including a layered review process with executive sign off on reports prior to submission.
Recommendation: We recommend that the District segregate all duties to ensure no single employee has access to assets and record keeping of those assets. Because of limited staff, we realize segregation of the above duties is not practical, if not impossible. Therefore, the responsibility of the ...
Recommendation: We recommend that the District segregate all duties to ensure no single employee has access to assets and record keeping of those assets. Because of limited staff, we realize segregation of the above duties is not practical, if not impossible. Therefore, the responsibility of the Business Manager is greatly increased because the Board must rely on her knowledge of the everyday operations to discover any material changes in the District’s financial position. Management’s Response: The District acknowledges this finding and has analyzed staffing; however, due to budget constraints finds it is not possible to hire the additional staff needed to put the controls in place to properly rectify this finding. Management’s Response: The District acknowledges this finding and, due to limited resources, cannot overcome this finding at this time but will put a plan in place to work towards improving controls to prevent or detect material misstatements in the preparation of the financial statements.
We are reviewing all accounting procedures to determine changes to be implemented.
We are reviewing all accounting procedures to determine changes to be implemented.
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. ...
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. The USDA has approved an action plan for the Facility to replenish the debt service reserve account by February 2028 with $5,000 monthly deposits which began in December 2024. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: December 31, 2024
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to thi...
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to third-party service platform transitions, two delays were related to students experiencing hardship (homelessness and mental health emergencies) and internal documentation gaps. Effect: Noncompliance with R2T4 deadlines may result in program findings, increased liabilities, and recurring audit scrutiny if unresolved. Corrective Actions for R2T4: 6. R2T4 Tracker Implementation o Action: Launch a live R2T4 tracker in Campus Café, flagged by withdrawal status and showing days remaining until the 45-day deadline. o Due Date: May 15, 2025 o Lead: Registrar, Business Office, Financial Aid Lead 7. Case Ownership Assignment Protocol o Action: Assign R2T4 responsibility to ECM and Business Office, written timelines and escalation criteria. o Due Date: May 15, 2025 o Lead: Executive Director 8. R2T4 Checklist & Escalation Framework o Action: Finalize a standardized checklist for all R2T4 cases including withdrawal date, calculation verification, fund return confirmation, and dual review. o Due Date: May 15, 2025 o Lead: Operations Manager 9. Quarterly R2T4 Audit o Action: Conduct quarterly compliance audits on all R2T4 files and include findings in compliance reports. o Due Date: First audit by June 30, 2025 o Lead: Compliance Officer 10. Emergency Circumstance Protocol o Action: Document a formal protocol for handling R2T4 cases with student hardship that allows internal escalation, verification, and documentation of exception handling. o Due Date: July 1, 2025 o Lead: Executive Director Monitoring Plan: Compliance will provide a quarterly report on R2T4 timeliness to the Executive Director. Any case that nears 35 days will be auto escalated for executive intervention.
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College shoul...
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College should evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS aligns with the College’s last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the work of a college-wide task force the following actions will be taken in response to the finding. The task force will include representatives from Information Technology, Institutional Research, Financial Aid, Registrar, along with Ellucian consultants. To summarize the steps and details of implementation to the specific areas are as follows: 1. Review Reporting Controls and Procedures 2. Address Error Code 22 3. Review Procedures Surrounding Reporting Status Changes 4. Assure Accuracy in Reporting Enrollment Effective Date Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Planned completion date for corrective action plan: December 31, 2026
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student...
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student financial information. We also recommend designating a qualified individual responsible for implementing and monitoring the institution’s information security program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College is working toward documenting its policy and procedures with the proper oversight and its continual monitoring of all GLBA guidelines and the sensitive student data therein. While the College has been in the practice of safeguarding all its sensitive student data and adhering to all the GLBA guidelines. It has not been properly documented. The qualified designated individual responsible for the implementation and continued monitoring is Jason Fried, College Director of Service Delivery and IT Compliance. Name(s) of the contact person(s) responsible for corrective action: Sara E. Gorton, CPA, Vice President for Business and Financial Affairs Holmer A. Avellan, CPA, CFE, Controller Jaime Hahn, Senior Auditor Stephen Clark, College Administrative Director of Infrastructure Services Jason Fried, College Director of Service Delivery and IT Compliance Planned completion date for corrective action plan: August 31, 2025 If the Department of Education has questions regarding this plan, please call: Sara Gorton, CPA, VP of Finance and Business Affairs 631-451-4223
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